Debate Revives Old Arguments on HPV Vaccine

The contention over requiring middle school girls to be vaccinated against the virus that causes cervical cancer had largely quieted before erupting again at a Republican presidential debate this month in Tampa, Fla.

At the Sept. 12 debate, U.S. Rep. Michele Bachmann, of Minnesota, and Rick Santorum, a former U.S. senator from Pennsylvania, attacked Texas Gov. Rick Perry for a 2007 executive order he issued that would have required 6th grade girls to be vaccinated against the human papillomavirus, or HPV, before starting school. They said the governor’s mandate represented the government intruding into a decision best left to parents.

The issue came up again at last week’s debate in Orlando in which Gov. Perry defended his actions, saying parents always had a choice in whether to get the vaccine for their daughters.

“I erred on the side of life, and I will always err on the side of life,” he said. “I don’t know what part of ‘opt out’ parents don’t understand.”

His order was later overturned by the Texas legislature but, even if it had taken effect, Texas would not be the only state today with requirements on the books aimed at either requiring HPV vaccinations or some form of HPV-prevention education targeted to preteens. Virginia and the District of Columbia now require the vaccine for young girls, though many more states have considered and dropped the idea since the vaccine was first introduced in 2006.

Soon after it was introduced in 2006, Gardasil, the first vaccine against some strains of the human papillomavirus, or HPV, which can cause cervical cancer, became the subject of debates over whether
to require it for young girls. Now, candidates vying to be the Republican Party’s nominee for president next year.
are rekindling those sensitive arguments.

—Charles Rex Arbogast/AP-File

Far more common has been passage of state laws that require teaching about HPV in school and sharing information with parents about where to get the vaccine, according to experts.

With or without laws requiring it, “what I have found in schools is, where they are talking about sexually transmitted diseases, HPV tends to be included,” said Elizabeth Schroeder, the executive director of Answer, a program based at Rutgers University, in Piscataway, N.J., that provides and promotes sexuality education to students and educators. “It used to be just [discussed] as genital warts, now they talk about cervical cancer and vaccines.”

HPV is the most common sexually transmitted infection, according to the federal Centers for Disease Control and Prevention. There are more than 40 types of the virus that can infect the genital areas of males and females as well as the mouth and throat. Most people who get the virus don’t know they have it, and the CDC says that in 90 percent of cases, the body’s immune system clears HPV naturally within two years. In some cases, however, an infection can lead to genital warts, cervical cancer, and cancers of the vulva, vagina, penis, anus, and the back of the throat. The strains of the virus that cause warts differ from those that cause cancer.

The two available vaccines protect women against some of the strains of the virus that cause cervical cancer. One brand, Gardasil, protects women and men against genital warts and other types of cancer, too, according to the drug’s manufacturer.

But because the vaccines protect against sexually transmitted illnesses, and because they are most effective in preventing an HPV infection when they are given as early as age 9, 10, or 11, some have argued the vaccines are a gateway to promiscuity. The reasoning is that when children know they are protected against an illness, they may become less cautious about having sex with multiple partners.

Vaccination Rates

Even with mandates in some jurisdictions aimed at requiring girls to be vaccinated for the human papillomavirus, or HPV, far fewer than 100 percent of girls between the ages of 13 and 17 have had the ﬁrst of three shots in the vaccination series. The highest vaccination rates for that age group are in Washington state, where the vaccine is not required but a state law calls for
providing parents with information on the vaccine and where they can get it. Although the District of Columbia is one of two jurisdictions that mandate the vaccine, only 57.5 percent of 13- to 17-year-old girls had gotten the ﬁrst of three shots required for the vaccine by 2010.

Washington State: 69.3%

South Dakota: 68.8%

El Paso County, Texas: 67.4%

Massachusetts: 65.9%

Delaware: 63.9%

City of New York: 62.7%

Hawaii: 62.7%

Philadelphia County, Pa.: 60.2%

Connecticut: 57.9%

District of Columbia: 57.5%

New York State: 56.2%

Sources: Centers for Disease Control and Prevention; National Conference of State Legislatures

Coupled with the general backlash against vaccines in recent years, which some have claimed could trigger autism and other illnesses, the HPV vaccine has been especially controversial.

During this month’s debate, Rep. Bachmann, referring to Gov. Perry’s executive order, said of the vaccine: “Little girls who have a negative reaction to this potentially dangerous drug don’t get a mulligan.”

The next day, Ms. Bachmann said a mother had approached her after the debate and said her daughter developed “mental retardation” after getting the HPV vaccine, which can have side effects similar to other vaccines, such as pain, redness, and swelling at the site of the shot.

The American Pediatric Association quickly refuted Ms. Bachmann’s claims. “There is absolutely no scientific validity to this statement,” the organization said. “Since the vaccine has been introduced, more than 35 million doses have been administered, and it has an excellent safety record.”

At the second debate this month, the moderator questioned Ms. Bachmann’s decision to share the unidentified mother’s account.

“I didn’t make that claim, nor did I make that statement. I only related what her story was,” Ms. Bachmann replied. Then she quickly turned the question back on Gov. Perry. “He gave parental rights to a big company,” she said.

One early supporter of the vaccine has recanted. Dr. Diane Harper, who helped research the effectiveness of both brands of the vaccine, said they don’t go far enough in reducing the odds that women will get cervical cancer.

Dr. Harper, a faculty member at the University of Missouri-Kansas City School of Medicine, added that the vaccines aren’t proven to remain effective as long as the manufacturers hope—up to 10 years, so vaccinating a girl at 11 may not be protective during her most sexually active years.

Roar to Whisper

In 2006, when the vaccines were first introduced, dozens of bills about the HPV vaccine cluttered state lawmakers’ desks, and the drugmaker of one of the vaccines was lobbying heavily for laws requiring it for girls along with more typical requirements for measles and whooping cough.

By this year, however, the debate in state legislatures over vaccine requirements for HPV for preteen girls had gone from a roar to a whisper. There were just three bills in statehouses involving the vaccine. One, in New York, proposes mandating the vaccine for students, according to the National Conference of State Legislatures, based in Denver.

Laws passed in other several other states mandate creating public-awareness campaigns about the causes and prevention of cervical cancer or require insurance companies to pay for the vaccine, said Karmen Hanson, a policy analyst for health for the NCSL.

Washington state is among those with a law requiring HPV to be addressed at school. In the Seattle public schools, Madison Middle School nurse Samara Hoag said students hear about HPV and the vaccines in 8th grade health class several times, both in discussions about sexually transmitted infections and in classes on birth control. Students can get the vaccine at any of the district’s 10 high school clinics or five middle school wellness centers.

“I would say that 100 percent of the girls seeking medical care will have a conversation with the nurse practitioner at some point about getting the HPV shot,” Ms. Hoag said in an email. “Last year we also started targeting boys to get the HPV shot.”

Mandates’ Effect

In the District of Columbia, girls entering 6th grade must either show proof that they have been vaccinated or that they are opting out. Virginia targets the same age group, but parents don’t have to fill out paperwork saying their children aren’t complying.

During the last school year, about 70 percent of public school 6th graders in the District of Columbia had been vaccinated, as had 93 percent of all 6th grade girls. The requirement extends to charter schools, parochial schools, and private schools. In Virginia, with no formal notice required when girls opt out, state records show only a small number of girls have been vaccinated, said Sandra Sommer, the quality-assurance and policy manager at the Virginia Department of Health. The CDC estimates that 54 percent of girls ages 13 to 17 in the state, slightly better than the national average, have had at least one of the series of three shots needed to be vaccinated. Nationwide, about 49 percent of girls in that age range have done the same, the CDC data show. All three shots must be given about two months apart for the vaccine to be effective.

The District of Columbia’s law hasn’t been challenged, and next spring, the school system will become the first in the country to give students a standardized test on health and sex education, in part because rates of sexually transmitted diseases and teen pregnancy are among the highest in the country. But Virginia’s law has been under fire ever since it was passed.

Several Virginia lawmakers who sponsored legislation to repeal the state’s requirement did not return phone calls or declined to comment to Education Week on the issue.

Some parents who have had their children vaccinated say at first, even they were skeptical.

Although her 21-year-old daughter, Caroline, has been vaccinated, Austin, Texas, parent Sara Stevenson said that didn’t happen until Caroline was a high school senior.

“I would have completely been against it” had her daughter been required to have the vaccine when Gov. Perry signed his executive order, Ms. Stevenson said. But now that time has passed, she believes she would feel differently.

In Ithaca, N.Y., parent Amy Cronin said HPV never came up at her daughter’s school. Erin, now 16, had heard about the vaccine from friends when she was younger.

Erin just finished her third shot in the HPV vaccine series, Ms. Cronin said. She decided she wanted to get the vaccine after she learned from her doctor that it can protect her against cancer.

“To me, the availability of what is a safe vaccine against a disease like cancer strikes me as something you would do for your child,” Ms. Cronin said, although she does believe people should have a choice about getting the vaccine.

New York Democratic state Assemblywoman Amy Paulin has stood firm on requiring the vaccine for all children born after 1996, including boys. She said the renewed interest in HPV could help her pass her bill. It has run into resistance from lawmakers in both parties.

“Hopefully,” she said, “the publicity will show that it’s a positive.”

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